6.19.2004

Onward to the ED

There are endless stories about King. Stories of triumph and success...but more commonly stories of failure, incompetence, and frustration. Let's start with last night.

I arrived for my shift at a quarter to seven pm. Got a feel for the department, and was happy to be back after a 2 month hiatus. I had two good interns, two good juniors, and a medical student...nice sized team. My sign-out was from a colleague, Dr. Ray, who initially was pissed at me, but was mature enough to *move on* once the issue was resolved. He's easily frazzled, and utterly frustrated by the workings of the Kingdom. He was made to stay an extra 6 months because of academic probation (meaning he pissed off the wrong people), and is very jaded, cynical, and ready to graduate. Anyway, it was a complete disaster, his sign out. I don't necessary make judgments about people based on the sign-out (as many other residents do). I feel like we all have bad days...sometimes it's just fucking busy...or your interns suck, or you're just tired. Whatever. This is what I signed up for...bring it on!!

So I get this sign out.
Ms. Ava, 50 yo hispanic, alcoholic female who presented c/o RUQ pain with N/V for 1 day after an ETOH binge of 2 days. Patient reeks of alcohol, but is not completely intoxicated. Her PMH is significant for DM (diabetes), HTN (hypertension), leukemia (in remission), and ALD (alcoholic liver disease). Dr. Ray's sign out was: drunk, probably pancreatitis, maybe cholecystitis, pending ultrasound and labs. She had been given a banana bag, phenergan, and ativan. We continued our rounds.

Then there was a lady, Ms. Marin. 55 yo obese AA woman with h/o HTN, CAD (coronary artery disease), with a c/c of sudden CP (chest pain) with SOB. Signed out first set of cardiac enzymes negative, pending CT chest.

CT chest? Any leg swelling? No. Any PE risk factors (other than obesity/sedentary)? No. Why the CT? Well, she had an Aa gradient of 33. Why did you get an ABG? Because of the history. Okay, so your suspicion is low for PE? Yes. (But obviously high enough to request chest CT). Moving on.

Mr. UK. 88 yo man (unsure of his country of origin, unsure of the language he speaks, unsure of his history, or even his chief complaint). Basically, there's this old guy, has some belly pain. The son said something about liver lesions (?septic emboli). He was here not long ago...but of course there's no record to be found. This guy has a temp of 101, a white count of 20K with a left shift. Did I mention he was 88 y/o? So...he was in the process of a complete re-workup. R/o (rule-out) septic emboli (from where? no one knows). R/o sepsis, r/o...basically everything.

Then there was Ms. Flores. 30ish y/o female with headache. H/O toxoplasmosis (what the hell??) and retinal necrosis, being treated. Okaaayyyy. Now with headache, white count of 15K, and no source. Signed out pending HCT (head CT), and then LP.

Let's not fail to mention these were the 4 most notable patients...the entire ER was full...all signout. About 23 patients total...for me!! With the above 4 being the most "interesting." The critical area is full. And there are no ICU beds in the hospital. Bruce was the CT tech (more about him later) so no one was going to get scanned before 11pm.

Let me run thru what happened to the patients. Ms Ava turned out to be tachycardic (rapid heart rate) in the 120s (which wasn't mentioned on rounds). Her labs came back (4 hours after they were requested) with a low bicarb. UA had ketones. What was her sugar I asked the nurse...no one knew. No accu check since early afternoon. Recheck and measured, about 300. Medical student draws ABG. Patient is in DKA (diabetic ketoacidosis). What?? It took 8 hours to discover she was in DKA?? For the record, her ultrasound and CT abd/pelvis were both negative. ETOH level was 69.

Ms. Marin had a right PA PE!! What?! MICU consulted. Let me say, however, it took until 5am to get that chest CT...10 hours after the sign out. What kind of place allows a PE sit undiagnosed therefore untreated, for 12 hours??!!

Mr. UK...well we never found out what his problem was. But it took until 5am to get the CT of the abdomen, and surgery won't come see the patient until the CT is done. So at 7am he was signed out by me to the oncoming team, pending medicine admission. No closer to the diagnosis.

Turned out Ms. Flores had clean CSF, and we discharged her right at 7am, 12 hours later...because that's when we got the CSF results.
***

Then there's this cleaning guy, who's rude and seems bitter because he doesn't speak English. He never says "hi" but humiliates folks in Spanish, as if most of us English speakers don't know enough Spanish to understand that's he's being rude. So he's machine dusting the ER floor...at 4am. Full ER, dust flying everywhere...with his mask on. *I* don't have a mask, the patients don't have masks...and they are the ones who are compromised. Finally, after the air was full of dirty ER floor dust particles, next to this 2 year old asthmatic, and the lady with the PE...I called the supervisor, and asked him to stop. Since the doctors have no power in a place like this, with their strong union...I begged them to stop.

I have a suggestion for the hospital. How about, instead of paying this guy whatever he's making to aggravate doctors and patients in the ER, why not hire...lets say...a NURSE so we can move some of these patients out of the ER and up to their beds. We have patients that stay in th ER, waiting for an ICU bed for 16 days!! Count them, 32 shifts!! How about...another CT tech, so we can get that CT chest in less than 12 hours. Oh, because this guy is union, and therefore cannot ever be fired. So, lets teach him English, and then his new job becomes interpretation...so we can talk to our patients. Pay him more for a service that's more necessary...he keeps his job, everyone wins...and most importantly, the union is happy.

Let's not forget about the crazy guy who beat up my intern. This guy comes in thru triage...for *nothing.* He says, I have these little bug bites on my legs. We look, he has 2 pimples, on on his thigh, and one on the opposite inner knee. He's been waiting...obviously, because he's not sick. So they bring him back...and the first clue that he's fuckin crazy is, he refuses to sit down. When patient's don't cooperate with a simple request without a reason, something is wrong. And I don't waste my time. If he's not sick, he can wait or cooperate...period. So he waited, and waited, until the intern got around to seeing him. Things seemed to be going okay...until the guy hauled off and hit the intern, in the head, and swung again and again. We called security, and they decided there were more important things going on. Finally they show up 5 minutes later...

...we'll he's here because he's sick...you want us to arrest him???

Hell yeah, get his ass outta my ER!! (GOMER) It's not okay to hit the doctor, and if you do, you go to jail, period!! Being drunk, crazy, mad, high, or otherwise, is no excuse to commit violent crimes. And if it's not okay in the street, it's not okay in the hospital. If he's sick and needs care, he can get it from jail...under the watchful eye of the police. And once he's "better" it can be decided what the reprecussions should be considering the circumstances. But loose, violent, in the ER isn't an option. We have a duty to protect ourselves (for our families), and to protect our other patients and staff. Hitting my intern, and staying, is not an option. So, reluctantly, they handcuff him, and take him to jail.

Wow.

Lastly, let me tell you about a couple of positive experiences. One child, 2 y/o, BIBM (brought in by mom) c/o left arm pain. Child was protecting the hand, holding it prone, flexed, close to the body. No h/o trauma. On exam no swelling or bruising. Hmm, nursemaid's elbow. So I hyperpronated...no response. (So much for ACEP lecture). Then (for the first time) I supinated/flexed, and reduced the elbow. Felt the pop...wha'la, all better. The child left as my best friend. Even taught the mom and dad how to do it, just in case it happens again. Very satisfying. And, then there was a young man with TMJ. Made the diagnosis easily after my ENT rotation...and they went home happy. Finally, the febrile seizure 10 mo old, came in twice in 14 hours. Baby had a cold, and mom wasn't giving enough Tylenol/Motrin...nothing more. But, if you come to the ER...be prepared to get stuck, poked, and prodded...even when it may not be necessary. So this kid gets the full septic w/u (which is of course negative). But obviously the LP really upset the mom...but later she thanked us, knowing that her child didn't have meningitis. And when the baby appeared normal (moving all extremities and such) after the procedure, she was relieved. I saw her checking the baby's feet and legs...standing the baby. Poor mom.

Well, I'm post shift...so I'm gonna end this here for today. Long night over...typical day at the Kingdom.